| Doctor Name: | BRADLEY PROVENCE |
| NPI Number: | 1225442155 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 7696 |
| Business Practice Address: | 7899 C St Millington, TN - 380532137 |
| Business Phone Number: | 9018722214 |
| Business Fax Number: | |
| Mailing Address: | 7899 C St, MILLINGTON |
| State: | TN |
| Postal Code: | 380532137 |
| Phone Number: | 9018722214 |
| Fax Number: | |
| NPI Enumeration Date: | 06/18/2014 |
| NPI Last Update Date: | 06/18/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1835N1003X |
| License Number: | 7696 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TN |
| Taxonomy Type: | Pharmacy Service Providers |
| Taxonomy Classification: | Pharmacist |
| Taxonomy Specialization: | Nutrition Support |
| Taxonomy Definition: | A licensed pharmacist who has demonstrated specialized knowledge and skill in maintenance and/or restoration of optimal nutritional status, designing and modifying treatment according to patient needs. |